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Family Planning - Michigan Local Public Health

VIEWS: 12 PAGES: 43

									                                            Michigan Local Public Health Accreditation Program
                                                                           Guidance Document


                            SECTION Q:
                         FAMILY PLANNING

Q1. The local health department had protocols at assure
    client confidentiality and provide safeguards for
    individuals against the invasion of personal privacy, as
    required by the Privacy Act. [Michigan Department of
    Community Health Standards and Guidelines, 2001 5.2]
      Q1.1 The local health department had protocols at assure client confidentiality
           and provide safeguards for individuals against the invasion of personal
           privacy, as required by the Privacy Act.

            To fully meet this indicator:

            a. No information obtained by the project staff about individuals receiving
               services may be disclosed without the individual’s consent, except as
               required by law or as necessary to provide services to the individual,
               with appropriate safeguards for confidentiality; AND

            b. Information may otherwise be disclosed only in summary, statistical, or
               other form that does not identify the individual.


Q2. The local health department has protocols and
    operating  procedures   for  emergency  situations.
    [Michigan Family Planning Standards and Guidelines,
    1998 2001: 7.3 A1--9; State of Michigan MPR 20,
    19992001]
      Q2.1 The local health department has protocols and operating procedures for
           medical emergencies.

            To fully meet this indicator:

            The local health department maintains on file emergency protocols and
            operating procedures which indicate appropriate recognition of the specific
            emergency and medical interventions for:

            a. Medical emergencies, this includes a policy specific to transportation
               ambulance service; AND

            b. Fainting and shock; AND

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            c. Cardiac arrest; AND

            d. Respiratory distress; AND

            e. Vasovagal response; AND

            f. Hemorrhage; AND

            g. The local health department clinic staff are trained to handle
               cardiopulmonary arrest, anaphylactic shock and the local health
               department maintains appropriate drugs and equipment to handle
               anaphylactic and vasovagal shock; AND [Michigan Family Planning
               Standards and Guidelines, 19982001: 8.8 A4] 10.2A7a-b)

            h. All medical staff Must be trained in CPR and hold current certification
               [Michigan Family Planning Standards and Guidelines ;2001: 7.3B;
               AND

            i.   Emergency arrangements must be available for after hours
                 management of contraceptive emergencies and weekend care and
                 musstmust be either posted, given to and/or explained to clients.
                 [7.0C1]; AND

            j.   Maintenance and monitoring of appropriate emergency resuscitative
                 drugs, supplies and equipment for the services provided. [Michigan
                 Family Planning Standards and Guidelines, 2001: 7.3 C]


      Q2.2 The local health department has protocols and operating procedures for
           non-medical emergencies. [Michigan Family Planning Standards and
           Guidelines, 2001: 7.3 A10]

            To fully meet this indicator:

            The local health department maintains on file emergency protocols and
            operating procedures to address:

            a. Fire. Fire routes or exit signs should be clearly posted in the facility
               and routine fire drills must be performed; AND [Michigan Family
               Planning Standards and Guidelines, 2001: 6.4 A2]

            b. There is documentation that drills are held at least annually; AND

            c. Natural disaster; AND

            d. Robbery; AND

            e. Power failure; AND

            f. Harassment.


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Q3. The local health department has financial management
    policies and procedures that comply with allowable
    costs of Title X projects and adheres to reporting
    requirements. [Michigan Family Planning Standards and
    Guidelines, 2001: 6.7; State of Michigan MPR 20, 2001;
    Title X]

      Q3.1 The local health department is in compliance with State and Federal
           financial management guidelines for allowable costs of Title X projects.
           [Michigan Family Planning Standards and Guidelines, 2001: 6.3]

            To fully meet this indicator:

            The local health department’s policies and procedures comply with the
            following:

            a. Charge, billing, and collection policies and procedures are in place,
               which include evidence that efforts to collect do not violate
               confidentiality; AND

            b. Charges are based on a cost analysis of all services, provided by the
               program; AND

            c. A schedule of discounts must be developed and implemented with
               sufficient proportional increments so that inability to pay is never a
               barrier to service. A schedule of discounts based on Maintains a
               current copy of the CSA Poverty Income Guidelines is required for
               individuals with family incomes between 101% and 250% of the
               Federal Poverty level.and a sliding fee scale developed from the
               Guidelines on file. There should be a clear definition of low income as
               below 100 percent of poverty and a clear understanding that clients
               below 100 percent poverty are not billed; AND

            d. Clients whose documented income is at or below 100% of the Federal
               Poverty level must no be charged; although projects must bill all third
               parties authorized or legally obligated to pay for services; AND

            e. Third party payers are billed total charges; AND

            f. Financial eligibility is documented in each client’s chart and is
               reassessed at least annually; ; AND
            g. Clients who are responsible for paying any fee for their services muyst
               be given a statement of charges (bill) directly; AND

            h. Client bills show total charges less any allowable discounts; AND


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            i.   Charges to minors requesting confidential services are based on the
                 resources of the minor; AND

            j.   Charges to unemancipated minors, where confidentiality is not a
                 concern, is based on family income; AND

            k. Clients services are not denied or limited in any wayservices because
               of inability to pay; AND

            l.   Client may make voluntary donations; however clients must not be
                 pressured to make donations, and donations must not be a
                 prerequisite for the provision of services and supplies. Donations from
                 clients do not waive the billing/charging requirements set out above;
                 AND

            m. Reasonable effort is made to collect bills without jeopardizing
               confidentiality; AND

            n. Charges to persons whose family income exceeds 250 percent of the
               poverty guidelines recover the reasonable cost of providing service;
               AND

            o. A method for aging accounts is in place; AND

            p. Payment agreements with contracted or referral providers are in place.
               [Michigan Family Planning Standards and Guidelines, 2001: 7.4 A1]

      Q3.2 The local health department adheres to reporting requirements. [Michigan
           Family Planning Standards and Guidelines, 2001: 6; State of Michigan
           MPR’s 22 and 26, 2001]

            To fully meet this indicator:

            The local health departments:

            a. Family Planning Annual Report (FPAR B formerly known as BCCR)
               meets all of the following requirements:

                    1) Financial tables are completed accurately and on time using
                       current financial data.

                    2) Tables 1, 1a, 2, 3, 4, 5, and 6 are complete.

                    3) Income for Title X and Medicaid are shown on Table 6.

                    4) Thirty (30) percent of the caseload is less than 19 years of age
                       OR the local health department is maintaining its percentage of
                       adolescents and has included an objective to increase teen
                       numbers.
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                  5) Eighty (80) percent of the caseload is women at less than 200
                     percent of poverty.

                  6) Males users are reported only if they meet the user definition for
                     family planning patients.

                  7) Donations are reported separately from patient fees and are
                     reported on Line 16, Table 6.

                  8) Pap-smear follow-up is in 100 percent compliance or an
                     approved corrective action plan is in place; AND

            b. Reliability and accuracy of data systems are monitored for missing
               user data, coding error editing, and data outcome; AND

            c. Quarterly sterilization reports are completed and submitted, if
               sterilizations are performed; AND

            d. Hepatitis B reports are submitted following vaccine administration;
               AND

            e. The program provides MICR information and registers clients under 20
               if they consent following Hepatitis B vaccine administration; AND

            f. If sterilization’s are performed, the local health department also
               maintains on file protocols for performing sterilization’s, assuring that
               requirements are met for age, voluntary informed consent, and waiting
               period.




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Q4. The local health department’s family planning clinic (s)
    adequately schedule appointments for family planning
    services.   [Michigan Family Planning Standards and
    Guidelines, 1998: 6.4; State of Michigan MPR 21, 1999]

I     Q4.1 The family planning clinic’s individual appointment system complies with
           Title X requirements and Michigan Department of Community Health
           standards. [Michigan Family Planning Standards and Guidelines, 2001
           7.0 D]

            To fully meet this indicator:

            a. The local health department maintains on file operating procedures for
               scheduling client appointments; servicing walk-ins, urgent problems
               and emergencies; and following-up on no-shows; AND

            b. A review of the appointment scheduling system reveals that:

                   1) Clients are scheduled for an appointment within two weeks of
                      calling; AND

                   2) Clients may make appointments for specific times for all types of
                      exams and when feasible, clients are scheduled for all needed
                      services on one visit; AND

                   3) Teens are scheduled for an appointment within two (2) to four
                      (4) days; AND

                   4) Clients receiving an initial exam receive service in less than two
                      (2) hours; AND

                   5) Clients receiving an annual exam receive service in less than
                      one and a half (1 ½) hours; AND

                   6) Supply clients receive services in less than half an hour; AND

                   7) Clients with positive pregnancy tests receive services in less
                      than one and a half (1 1/2) hours; AND

                   8) Supply pickup times are scheduled at various times of the day
                      and week; AND

                   9) Evening, or Saturday appointments are available; AND

                   10)Patients needing urgent care and emergency contraception are
                      scheduled immediately or accommodated by walking in; AND
                   11)The no show rate is 30% or less; AND

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                   12)It is recommended that periodic Patient Flow Analysis (PFA) is
                      done at least every 3 years and modifications in the schedule
                      are made based on PFA results. [Michigan Family Planning
                      Standards and Guidelines, 2001: 10.4 B7]


Q5. The local health department assesses community need
    related to family planning and develops a plan to
    address community need. [Michigan Family Planning
    Standards and Guidelines, 2001: 3.2; State of Michigan
    MPR 18, 2001]

      Q5.1 The local health department assesses community need related to family
           planning and develops a plan to address community need.

            To fully meet this indicator:

               a. The local health department maintains on file an annual plan which
                  includes the results from a needs assessment (the methodology for
                  assessment should be detailed in the plan), a progress report on
                  the previous year’s goals, annual goals and objectives, services to
                  be provided, and projected caseload. Michigan Department of
                  Community Health Family Planning Standards and Guidelines,
                  2001: 3.2A1-6.
                         The plan must include:
                         i. A description of the geographic area includigincluding a
                              discussion of potential geographic, topographic and other
                              related barriers to service; AND
                         ii. Demographic description of the service area including
                              objective data pertaining to individuals in need of family
                              planning services, maternal and infant mortality/morbidity
                              rates, birth rates and percentages of unintended
                              pregnancies by age groups, poverty status of the
                              populations to be served, cultural and linguistic barriers
                              to service, etc.; AND
                         iii. Description of exisitingexisting services and need for
                              additional    family     planning   services   to    meet
                              community/cultural needs; AND
                         iv. Need indicators that include rates of STDs and HIV
                              prevalence (Including perinatal infection rates) in the
                              service area; AND
                         v. Identification and description of linkage with other
                              resources related to reproductive health; AND
                         vi. Identification and discssiondiscussion of high priority
                              populationslulatios and target areas.
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                b. Goals and objectives must be clearly stated, listed in order of
                   priority, be specific, realistic, measurable, and have a time frame for
                   completion, be compatible with Title X requirements and Michigan
                   Department of Community Health standards, and reflect state and
                   federal objectives.           Objectives must include community
                   participation, program promotion, community education, and
                   evidence that low-income individuals are given services priority and
                   that low-income women, teens, minorities, and other underserved
                   populations are included in the target group.This can be
                   accomplished as part of a community health assessment and
                   improvement process.


Q6. The local health department educates and promotes the
    community related to family planning services and
    promotes family planning services in the community.

      Q6.1 The local health department has a community-based family planning
           advisory and/or education committee, representative of the population
           served, that meets at least twice a year and provides general direction for
           the family planning program and provides education on family planning
           services to the community. [Michigan Family Planning Standards and
           Guidelines, 2001: 4.0; State of Michigan MPR 8, 2001]

            To fully meet this indicator:

            The local health department maintains on file:

            a. Agencies provide an opportunity for participation in the development,
               implementation and evaluation of the project by (1) persons broadly
               represented of all significant elements of the population to be served
               and (2) persons in the community knowledgeable about the
               community’s need for family planning services [Michigan Department
               of Community Health Family Planning Standards; 2001: 3.4A20

            b. An advisory committee of five to nine members who are broadly
               representative of the community must review and approve all
               informational and education materials developed of made available
               under the project prior to their distribution; AMembership roster(s),
               indicating membership consists of between five (5) and nine (9)
               members and that membership is representative of the population
               served. Teens, low-income women, and members of minority groups
               must be actively sought for participation; AND



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            c. The I&E advisory committee may serve the community participation
               functions if it meets the above requirements, or a separate group may
               be identified; AND

            d. Minutes of committee(s) meetings which document recommendations,
               actions taken, meetings dates, and attendance; AND

            e. Evidence, such as meeting minutes, that the committee(s) has
               reviewed and concurred with the local health department’s family
               planning program, and methods and that educational materials are
               approved by the local health department’s Information and Education
               Advisory or Family Planning Advisory Committee prior to
               disbursement. This can be evidenced through meeting minutes; AND
               [Michigan Family Planning Standards and Guidelines, 2001: 4.0A3]

            f. By-laws or description of the committee(s) duties and responsibilities
               that include a statement of purpose; AND

            g. A written community education plan evidenced in the annual plan that
               defines the local health department’s implementation and evaluation
               strategy.      The community education objectives must include
               identification of specific target groups, such as teens, migrants, and
               homeless individuals, and HIV/AIDS education and at least one of the
               following: developing and maintaining a positive community climate for
               program activities; coordination with other agencies to avoid gaps in
               and duplication of services; outreach to clients of agencies likely to
               provide services to those in need of family planning services; or
               orientation of professional staff of agencies likely to counsel or refer
               clients for family planning services; AND [Michigan Department of
               Community HelathHealth Family Planning Standards and
               Guidelines ;2001A: 6.10A]

            h. A written plan that details how the local health department will promote
               community awareness of the agency’s family planning goals, inform
               the community of services provided, promote continued participation in
               the program by persons to whom family planning services may be
               beneficial, and yearly caseload and outreach targets. The plan must
               specifically delineate outreach strategies targeted at low-income
               women, teens, minority groups, and other underserved populations
               (i.e., HIV carriers, IV drug users, prostitutes, lesbians); AND [Michigan
               Family Planning Standards and Guidelines, 2001: 6.11 A]

            i.   Evidence that all staff received training regarding the unique socio-
                 cultural practices, beliefs and customs of the under-served populations
                 of their service area; AND [Michigan Family Planning Standards and
                 Guidelines, 2001: 6.6 A6]

            j.   Brochures, agendas or outlines from promotional meetings/sessions,
                 or public service announcements used in program promotion. This

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               could include evidence that peer counselors, teen theater, or
               community health advocates are used and documentation of
               community education activities such as outreach logs or evaluations of
               education activities, speakers provided by the local health department,
               and program effectiveness.

      Q6.2 The local health department has operating procedures for providing
           medical client education about contraceptives, HIV/AIDS, and STIs that
           comply with federal Title X requirements and Michigan Department of
           Community Health. [State of Michigan MPR’s 20, 23, 25, 19992001;
           Michigan Department of Community Health Family Planning Standards
           and Guidelines 2001:7.2A(7) a-b.]

            To fully meet this indicator:

            The local health department’s materials, including electronic materials,
            acknowledge federal grant support in any publication and are subject to
            royalty free, non-exclusive, and irrevocable license or right to the
            Government to reproduce, translate, publish, use, disseminate, and
            dispose of such materials and to authorize others to do so . The work
            “publication is defined to include computer software. [Michigan Family
            Planning Standards and Guidelines 2001: 6.10A] AND Iinformational and
            educational materials:

            a. Reflect Title X requirements and Michigan Department of Community
               Health standards policies regarding discrimination, coercion, client
               eligibility, education about all methods of contraception, provision of
               services which do not include abortion as a method of family planning,
               options of managing unplanned pregnancies, confidentiality, client
               charges, the Americans with Disabilities Act, and do not contain
               information that is contrary to accepted medical practice; AND
               [Michigan Family Planning Standards and Guidelines, 2001: 6.8 B2,
               6.13 C]

            b. The local health department maintains on file client education
               procedures for providing information on all contraceptive methods,
               including the birth control pill, emergency contraception, condoms,
               diaphragm, cervical caps, IUD, natural family planning, spermicides,
               injectible contraceptives, Norplantcontraceptive implants, , abstinence,
               and sterilization. Information on newly available methods must be
               available. Contraceptive information must include detail on the safety,
               effectiveness, benefits, risks, side effects, complications, protection
               against STI’s and correct usage of all contraceptives; AND [Michigan
               Family Planning Standards and Guidelines, 19982001: 8.1 A1]

            c. The local health department provides educational opportunities to clinic
               clients through group discussion, film or videotape, pamphlets, or one-
               to-one discussion; AND [Michigan Family Planning Standards and
               Guidelines, 2001: 8.1 A6]
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            d. Client education must be documented in the client’s chart. The
               education provided should be appropriate to the client’s age, level of
               knowledge, language and sociocultural background and be presented
               in an unbiased manner; AND [Michigan Family Planning Standards
               and Guidelines, 19982001: 6.98 B4 and 5]

            e. changes or selected based on client input.           The local health
               department maintains on file evidence of client review of materials prior
               to distribution, such as client questionnaires; AND [Michigan Family
               Planning Standards and Guidelines, 2001: 6.10 A1]

            f. Are reviewed periodically to assure that information is factually correct
               and up to date. [Michigan Family Planning Standards and Guidelines,
               2001: 6.8 B3]; AND

            g. A review process is in place to insure currency and accuracy of
               information.


Q7. The local health department assures the quality of the
    clinical and educational components of the family
    planning program. [Michigan Family Planning Standards
    and Guidelines, 2001: 10.4 A; State of Michigan MPR 20,
    2001]

      Q7.1 The local health department has a quality assurance system in place to
           evaluate the quality of the clinical and educational components of the
           family planning program.

            To fully meet this indicator:

            a. Written and annually updated plans and operating procedures,
               including a system to implement corrective action when deficiencies
               are noted, and Quality Assurance activities assure that all
               requirements of the family planning program are met; AND [Michigan
               Family Planning Standards and Guidelines, 2001: 10.4 B]

            b. Minutes of quality assurance meetings; AND [Michigan Family
               Planning Standards and Guidelines, 2001: 10.4 B3]

            c. A tracking system to identify clients in need of follow-up, such as a
               computer or tickler system. [Michigan Family Planning Standards and
               Guidelines, 2001: 10.4 B3]; AND



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            d. Staff evaluations occur annually as part of the quality assurance
               system [Michigan Family Planning Standards and Guidelines;
               2001:6.5B6]

      Q7.2 The local health department monitors client satisfaction with Title X
           services provided by both the local health department and referred
           services.
      I
           To fully meet this indicator:

            The local health department maintains on file:

            a. Copies of completed client satisfaction surveys, client surveys of
               needed services or results from focus groups conducted to determine
               potential improvements in services; AND [Michigan Family Planning
               Standards and Guidelines, 2001: 10.4 B8]

            b. Documentation of changes made in response to client input, where
               indicated, and with input from the Advisory Council. [Michigan Family
               Planning Standards and Guidelines, 2001: 10.4 B8a]

      Q7.3 The local health department evaluates the quality of family planning
           counseling services.    [Michigan Family Planning Standards and
           Guidelines, 2001: 8.1]

            To fully meet this indicator:

            a. The local health department maintains on file written procedures for
               evaluating the quality of its counseling. The evaluation must include
               consideration of whether staff are knowledgeable, objective,
               nonjudgmental, sensitive to individual rights and differences, and able
               to create an environment conducive to discussing personal
               information; AND

            b. Accompanying a client through the clinic reveals that staff members
               introduce themselves to client; the client is treated with courtesy and
               respect; the client is given opportunity to participate in planning her/his
               own treatment; and service delivery promotes an atmosphere in which
               clients feel free to ask questions and voice concerns; AND

            c. The local health department has specific protocols and operating
               procedures for providing counseling education and information on
               services such as HIV, pregnancy, infertility and, preconceptional health
               counseling and male servicesare on file.

Q8. The local health department has protocols and
    operating procedures for equipment and supplies.
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      [Michigan Family Planning Standards and Guidelines,
      19982001: : 11.1, 10.4 B10;6.310.1 A and B; State of
      Michigan MPR’s 9 and 20, 19992001]

      Q8.1 The local health department’s protocols and operating procedures for
           equipment and supplies comply with Title X requirements and Michigan
           Department of Community Health standards guidelines.

            To fully meet this indicator:

            Direct observation, review of records, and/or written protocols and
            operating procedures indicate:

            a. Equipment and supplies are kept in a safe and secured area, adequate
               to meet service demands, appropriate to the type of service offered,
               maintained in good working order, records of equipment purchased
               with grant related funds are verified during inventory, inventoried
               annually by one designated individual; AND

            b. A specific individual at each site is responsible for maintenance and
               selection of equipment and supplies; AND

            c. A log is maintained to document equipment maintenance; AND

            d. Disposition of equipment and supplies is in compliance with federal
               and state regulations; AND [Michigan Family Planning Standards and
               Guidelines, 2001: 6.3A]

            e. A system is in place to safeguard against loss, theft or damage of
               equipment or supplies.




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Q9. The local health department has protocols and
    operating procedures for pharmaceutical distribution.
    [Michigan Family Planning Standards and Guidelines,
    19982001: 11.210.2; State of Michigan MPR’s 9 and 20,
    19992001; P.A. 333. (of 1990368 as amended under the
    Pharmacy Practice and Drug Control 333.17745)]

      Q9.1 The local health department has protocols and operating procedures for
           the distribution, security and record keeping of pharmaceuticals that
           adhere to all applicable federal and state regulations.

            To fully meet this indicator:

            The local health department:

            a. Maintains on file written protocols and operating procedures for the
               distribution, security and record keeping of pharmaceuticals that
               adhere to all applicable federal and state regulations; AND

            b. The medical director of dispensing physician maintains a Drug Control
               License---------------------- AND

            c. All medications except prepackaged and prelabled oral contraceptives
               are distributed by a nurse or physician; AND

            d. The label must contain the following information:

               1. The name and address of the location from which the prescription
                  drug is dispensed.
               2. The patient’s name and record number.
               3. The date the prescription drug was dispensed.
               4. The prescriber’s name.
               5. The directions for use.
               6. The name and strength of the prescription drug.
               7. The quantity dispensed.
               8. The expiration date of the prescription drug or the statement
                  “discard this medication one year after the date it is dispensed”;
               9. Lot number AND

            e. Vaccines for immunizations are stored according to manufacturer’s
               recommendations; AND

            f. Maintains on file a listing (formulary) of all drugs stocked that is revised
               annually; AND
            g. Maintains on file and additional listing of pharmaceuticals that may be

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                 ordered, but are not stocked; AND

            h. Purchases and uses generic drugs based on therapeutic equivalence
               as published by the Federal Drug Administration or in the Formularies
               of Therapeutic Equivalence accepted by the State Board of Pharmacy;
               AND

            i.   A system is in place to monitor the expiration date on drugs and
                 ensure disposal of all expired drugs; AND

            j.   Double locks and separates from other drugs narcotics or tranquilizers,
                 and takes a count of controlled substances at the beginning and end of
                 each day or clinic session; AND

            k. Has a system for silent notification in case of drug recall; AND

            l.   Has documented that in-service training on the nature and safety of
                 pharmaceuticals has been provided to staff involved in the provision of
                 medications to clients.

      Q9.2 Each of the local health department’s clinics maintained an adequate
           supply and variety of drugs and devices to meet the contraceptive needs
           of clients.

            To fully meet this indicator:

            A review of the supply of contraceptives in stock include:

                       a. Hormonal contraceptives in a variety of dosages, routes and
                          combinations; including DMPA, Lunelle, oral contraceptives
                          and emergency contraception; AND

                       b. IUDs and Implants if provided on site; AND

                       c. Diaphragms/cervical caps in various types and sizes; AND

                       d. Male and female condoms; AND

                       e. Spermicidal agents such as foams, creams, jellies, film.

Q10.The local health department has protocols and
    operating procedures for maintaining medical records.
    [Michigan Family Planning Standards and Guidelines,
    2001: 10.3; State of Michigan MPR’s 9 and 20, 2001]

      Q10.1 The local health department maintains medical records in accordance with
            Title X requirements, Michigan Department of Community Health

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            standards and accepted medical standards for all clients receiving medical
            services.

            To fully meet this indicator:

            A review of randomly selected medical records indicate:

            a. All male and female clients receiving medical services have a medical
               record, including pregnancy testing, HIV and other counseling clients;
               AND [Michigan Family Planning Standards and Guidelines, 2001: 10.3
               A1]

            b. Entries on client records are uniform as to format and content, in
               chronological order, and signed and dated. Entries must be written in
               black ink or typed and must be legible and accurate; AND [Michigan
               Family Planning Standards and Guidelines, 2001: 10.3 A2]

            c. A signature log is used if full name is not written on entries; AND

            d. All telephone calls from clients with medical concerns are accurately
               documented; AND         [Michigan Family Planning Standards and
               Guidelines, 2001: 10.3 B16]

            e. Signed and dated consent forms covering examination and treatment,
               including, as applicable, General Treatment (must be signed by all
               clients); Prescriptive Contraception (method specific); Pregnancy
               Testing; Sterilization; or Release of Information. Consent forms must
               cover all procedures and medications and contain statements that
               consent was given voluntarily, education and counseling was provided,
               questions were answered, and client understands the content of
               information given. Consent must be written in the primary language of
               the client or an interpreter must be used. If the client is mentally
               incompetent, a special consent form must be used and a parent or
               guardian must also sign; AND [Michigan Family Planning Standards
               and Guidelines, 2001: 8.1 B]

            f. Individual counseling occurs before client makes choice of method or
               signs consent; AND [Michigan Family Planning Standards and
               Guidelines, 2001: 8.1 B1]

            g. Consent must be updated in response to change in health status or to
               new prescriptive method and must reflect current knowledge relating to
               the methods of birth control; AND        [Michigan Family Planning
               Standards and Guidelines, 2001: 8.1 B4]

            h. Parental or partner consent is not required for services; AND

            i.   For teens, family involvement is encouraged and documented in the
                 chart; AND [Michigan Family Planning Standards and Guidelines,
                 2001: 8.1 B4]
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            j.   Assurances of confidentiality statement appear on history forms or
                 another place within the medical record; AND [Michigan Family
                 Planning Standards and Guidelines, 2001: 10.3 B10]

            k. Medical history; AND [Michigan Family Planning Standards and
               Guidelines, 2001: 10.3 B1e]

            l.   Results of physical exam; AND [Michigan Family Planning Standards
                 and Guidelines, 2001: 10.3 B10]

            m. Results of clinical findings, diagnostic and therapeutic orders, including
               documentation of clinical information that justifies treatment or end
               result; AND [Michigan Family Planning Standards and Guidelines,
               1998: 10.3 B1e]

            n. Lab test results and follow-up of abnormal results is documented; AND
               [Michigan Family Planning Standards and Guidelines, 2001: 10.3 B1h]

            o. Documentation of all treatments initiated or contraceptive methods
               provided; AND [Michigan Family Planning Standards and Guidelines,
               2001: 11.3 B1m]

            p. Documentation of all special instructions; AND [Michigan Family
               Planning Standards and Guidelines, 2001: 11.3 B1I]

            q. Documentation of all continuing care, counseling, referral, education,
               social services, and follow-up services (including scheduled revisits).
               Education provided related to contraceptives, HIV/AIDS, and STI’s
               must be documented. For referrals, documentation in medical records
               indicates the client was allowed to select referral provider; consent was
               obtained prior to release of pertinent information to referral provider;
               reason for referral, services to be received from the referral agency
               and directions to the referral agency were explained; and a date to
               return to the family planning clinic was scheduled; AND [Michigan
               Family Planning Standards and Guidelines, 2001: 7.2 D, 7.4 A2]

            r. Documentation of emergency referrals; AND          [Michigan Family
               Planning Standards and Guidelines, 2001: 11.3 B1i]

            s. An optional problem list at the front of chart; AND [Michigan Family
               Planning Standards and Guidelines, 2001: 11.3 B1p]


            t. For transfer clients, history is completed and a method-specific
               consent form is signed and a breast exam is performed offered if the
               woman is over 30 and choosing a hormonal method of contraception.
               If the client's last exam occurred over 12 months, the client is treated

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                as a new client. [Michigan Family Planning Standards and Guidelines,
                19982001: 11.210.2 B]

            u. HIV, mental health and substance abuse information is handled
               according to law, and kept

      Q10.2 The local health department maintains a system for filing, retrieving, and
            storing medical records. [Michigan Family Planning Standards and
            Guidelines, 2001: 11.3 A2]

            To fully meet this indicator:

            The local health department maintains:

            a. The client’s family planning chart separate from the client’s other
               service charts; AND

            b. An efficient system for filing and retrieving charts. Records must be
               available to clients upon request and locked when not in use, and
               access to records must be limited on a need-to-know basis; AND

            c. A system for storage and destruction of records. This must include a
               system for identifying inactive clients and purging inactive files.

      Q10.3 The local health department has a system for performing a medical audit.
            [Michigan Family Planning Standards and Guidelines, 2001: 10.4 B]

            To fully meet this indicator:

            a. The local health department’s Medical Director or designee reviews a
               reasonable number of randomly selected charts at least
               quarterlymonthly   for   completeness     and     accuratenessIt   is
               recommended that at least twenty (20) medical records per clinic site
               per month be reviewed by the Quality Assurance Committee and five
               (5) medical records from each clinician be reviewed monthly; AND
               [Michigan Family Planning Standards and Guidelines, 19982001: 11.3
               D310.4B3]

            b. The local health department has evidence that client records are
               periodically monitored. This must include post clinic medical record
               review where problems are logged and resolved. Additionally, periodic
               or intermittent random chart audit must be performed by category or
               combination of categories: [Michigan Family Planning Standards and
               Guidelines, 19982001: 11.3 D]10.4B3

                                 1.   New users
                                 2.   Continuing users
                                 3.   Specific topics (e.g., methods, problem diagnosis)
                                 4.   Age group (e.g., teen, over 35); AND

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            c. A system is in place to identify documentation or clinical practice
               problems and resolution or follow-up of problems identified above.


Q11.The   local  health   department’s  General  Clinic
    Procedures and Clinician Service Protocols are in
    compliance with Title X requirements, and Michigan
    Department of Community Health standards.
      Q11.1 The local health department has General Clinic Procedures and Clinician
            Service Protocols in compliance with Title X requirements and Michigan
            Department of Community Health standards.

            To fully meet this indicator:

            a. The local health department maintains current clinical practice
               resources, such as the text of Contraceptive Technology Update or CT
               Update Newsletter or the NP journalDickeys Managing Oral
               Contraceptive Patients, or Journal of Obstetrics and Gynecology; AND
               [Michigan Family Planning Standards and Guidelines, 19982001: 6.6
               D]

            b. The local health department maintains on file, at each site, a General
               Clinic Procedure Manual [See Appendix E at the end of Section Q] and
               Clinician Service Protocol Manual(s) that are in compliance with Title X
               requirements, Michigan Department of Community Health standards;
               AND [Michigan Family Planning Standards and Guidelines, 2001: 7.0
               B]

            c. Voluntary participation by clients and acceptance of family planning
               services is not a prerequisite to receiving other services; AND
               [Michigan Family Planning Standards and Guidelines, 2001: 3.4 A2]

            d. Access to persons with limited English profiencyproficiency is assured
               and assistance is provided that results in accurate and effective
               communication with the client with no financial cost to the client; AND
               [3.4A3-4]

            e. Provide services in a manner that will protect individual dignity and
               respect diverse social and cultural practices of the population to be
               served; AND

            f. Services are provided without residency requirement or physician
               approval; AND [Michigan Family Planning Standards and Guidelines,
               2001: 3.4 A5, 5.2 A]



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            g. Sterilization services provided on-site comply with standards for out-of-
               hospital sterilization’s; AND [Michigan Family Planning Standards and
               Guidelines, 2001: 6.7 C]

            h. Services do not include abortion as a method of birth control; AND
               [Michigan Family Planning Standards and Guidelines, 2001: 3.4 A5]

            i.   Signatures by the medical director and clinicians indicating procedures
                 and protocols are updated annually and evidence of training if changes
                 in protocol occur between annual reviews; AND [Michigan Family
                 Planning Standards and Guidelines, 2001: 6.5 B2]

            j.   Practitioner signature on all established protocols or on cover sheet;
                 AND [Michigan Family Planning Standards and Guidelines, 2001: 6.5
                 B7]

            k. As applicable, copy of waiver requests submitted for exemption from a
               particular requirement and documentation, such as a letter or
               memorandum, from the Michigan Department of Community Health
               indicating approval of the waiver request; AND [Michigan Family
               Planning Standards and Guidelines, 2001: 7.1 C]

            l.   A patient rights and responsibilities poster is displayed or given to the
                 patient. [Michigan Family Planning Standards and Guidelines, 2001:
                 7.0 E]


Q12.The local health department has protocols and
    operating procedures for providing services to
    adolescents. [State of Michigan MPR 26, 2001]
      Q12.1 The local health department has specific protocols and operating
            procedures for providing services to adolescents. [Michigan Family
            Planning Standards and Guidelines, 2001: 8.7]

            To fully meet this indicator:

            a. The local health department addresses service delivery to adolescents
               in their annual plan; AND

            b. A review of medical records, direct observation and written protocols
               and operating procedures related to adolescents demonstrate all the
               following items are assured:

                    1) Written consents of parents or gaurdiansguardians is not
                       required for the provision of services; AND
                    2) Parents are not notified before of after services are requested or
                       received AND
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                   3) Specialized, confidential counseling and follow-up services are
                      provided. [Michigan Family Planning Standards and Guidelines,
                      2001: 8.7 B1]

                   4) Adolescent are encouraged to participate in decisions related to
                      receiving medical services.    This is mandatory prior to
                      dispensing any prescriptive methods.         [Michigan Family
                      Planning Standards and Guidelines, 2001: 8.7 C1e]

                   5) Documentation of encouragement of parental involvement.
                      [Michigan Family Planning Standards and Guidelines, 2001: 8.1
                      B4]

                   6) Information on all methods of contraception is given and
                      abstinence is discussed as an option.       [Michigan Family
                      Planning Standards and Guidelines, 2001: 8.7 C1F]

                   7) An atmosphere conducive to questions, discussion is created.
                      [Michigan Family Planning Standards and Guidelines, 2001: 8.7
                      B1E]

                   8) Teens are asked about symptoms and exposure to STI's or HIV
                      and high risk teens areexposures to STI’s or HIV and high-risk
                      teens are encouraged to be tested and treated, as indicated.
                      [Michigan Family Planning Standards and Guidelines,
                      19982001: 8.7 B1F]

I     Q12.2 The local health department has specialized services for teens. [Michigan
            Family Planning Standards and Guidelines, 2001: 8.7 C]


            To fully meet this indicator:

            a. The local health department maintains on file a list of the type of
               specialized services available such as:

                   1) Teen peer counselors; OR

                   2) Special walk in or scheduled clinic hours for teens; OR

                   3) Teen focused community education programs; OR

                   4) Opportunity for priority clinic scheduling within 2-4 days; OR

                   5) Delegate agency staff represent the program on teen pregnancy
                      task forces, or other community initiatives focused on
                      adolescents.


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Q13.The local health department has protocols and
    operating procedures for performing initial and annual
    visits. [State of Michigan MPR 9, 1999]

      Q13.1 The protocols for conducting an initial medical visit comply with Title X
            requirements and Michigan Department of Community Health standards.
            [Michigan Family Planning Standards and Guidelines, 2001: 8.3]

            To fully meet this indicator:

            A chart review or observation of clinicians conducting an initial medical
            visit indicates that during a medical visit, clients provide or receive the
            following information:

            a. Personal and family history. At a minimum, the woman’s medical
               history must include information on: [Michigan Family Planning
               Standards and Guidelines, 2001: 8.3.1A 1,2]

                   1) Allergies
                   2) Immunizations, esp. rubella and Hepatitis B
                   3) Current medications
                   4) Hospitalizations
                   5) Cancer
                   6) Cardiovascular disease
                   7) Gynecological history, including date of last menstrual period, in
                      utero exposure to DES, and any problems
                   8) Pregnancies
                   9) Sexual risk behavior
                   10)History of blood transfusion prior to 1984 or exposure to
                      substance abuse
                   11)Drug/substance abuse
                   12)Current or previous methods of birth control, including reasons
                      for discontinuing use
                   13)Major illnesses
                   14)Sexually transmitted infections
                   15)High cholesterol/early coronary artery disease
                   16)Hyperlipidemia
                   17)Blood clots
                   18)Hepatitis
                   19)Epilepsy
                   20)Migraine headaches
                   21)Diabetes
                   22)Hypertension
                   23)Partner history (indictable drug use, multiple partners,
                      bisexuality, risk history for STIs and HIV)



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            b. For females, an examination of height and weight, blood pressure,
               thyroid, heart and lungs, extremities, breast (including instruction in
               self-exam), abdomen, and pelvic (speculum) and bimanual should be
               included. Colo-rectal screening for individuals over 40 must be
               provided ; AND [Michigan Family Planning Standards and Guidelines,
               19982001: 8.3.2 A1a,b]

            c. For males, medical history should include sexual activity, risk for STIs
               and HIV/AIDS, fertility, and in utero exposure to DES. An examination
               of height and weight, blood pressure, thyroid, heart and lungs,
               extremities, genitals and rectum, including palpation of the prostate,
               and instruction in self-exam of the testes should be included. ;
               Colorectal screening must be provided for individuals over 40; AND
               [Michigan Family Planning Standards and Guidelines, 19982001: 8.3.3
               A23b]

            d. Physical examination and related prevention services should not be
               deferred beyond three months after the initial visit and in no case may
               be deferred beyond six months, unless if in the clinicians’ judgement,
               there is compelling reasons for extending the deferral; AND [Michigan
               Family Planning Standards and Guidelines 2001: 8.3.2 A3a]

            e. All deferrals, including the reason(s) for deferral must be documented
               in the client chart AND [Michigan Family Planning Standards and
               Guidelines 2001:8.3.2A3b]

            f. Protocols are available regarding deferrals AND

            g. A presentation of relevant educational materials including information
               about the value of fertility regulation, all contraceptive methods, male
               and female reproductive anatomy, reproductive health, health
               promotion/disease prevention, required parenting brochure, and
               AIDS/HIV; AND [Michigan Family Planning Standards and Guidelines,
               19982001: 8.1 A1,2]

            h. Is prior to IUD insertion if indicated by history or prior exam findings;
               AND [Michigan Family Planning Standards and Guidelines, 19982001:
               8.3.5A1

            i.    Necessary medical procedures; AND

            j.    Medication and/or supplies; AND

            k. Exit counseling which includes written, specific instructions on chosen
               method, including instructions on danger signs and actions to take in
               case of emergency. [Michigan Family Planning Standards and
               Guidelines, 2001:8.2 B1]

Q14.The          local    health     department          has      protocols         and
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      operating procedures for providing counseling services.
      [State of Michigan MPR 10, 24, 2001]

      Q14.1 The local health department provides counseling services in compliance
            with Title X requirements and Michigan Department of Community Health
            standards.

            To fully meet this indicator:

            A review of protocols and operating procedures indicate that:

            a. During a visit the client is informed of confidential treatment of
               information and medical records and their right to refuse release of
               information to any individual except as required by law or third party
               payor contract; right to voice grievances and of agency's procedure for
               handling grievances; and right to refuse to participate in research, if
               applicable; AND         [Michigan Family Planning Standards and
               Guidelines, 1998: 7.0 E, 7.0 H, 7.1 B4]

            b. Clinical staff give accurate and up to date information on risks,
               benefits, contraindications and effective use of any method, procedure,
               treatment or option being considered; AND [Michigan Family Planning
               Standards and Guidelines, 2001: 8.1 A1]

            c. Client-centered counseling is provided to all clients on HIV/AIDS and
               offers testing; AND      [Michigan Family Planning Standards and
               Guidelines, 2001: 8.1A8]

            d. Substance abuse history is taken, education, and referral is provided
               and appropriate follow-up is conducted. The local health department
               maintains on file evidence of collaboration with community substance
               abuse centers for referral of clients; AND

            e. Post-exam (exit) counseling assures the client knows results of
               physical exam; results of lab tests; how to use chosen method. (Should
               be given written instruction); method specific common side effects,
               possible complications and what to do if they occur; when to return for
               revisit; emergency phone number and/or location where emergency
               services can be obtained; information on referrals and follow-up, if
               appropriate; AND [Michigan Family Planning Standards and
               Guidelines, 2001: 9.6]
            f. Special counseling services, such as preconceptional, management of
               current pregnancy, sterilization, infertility, genetic, nutritional, and
               adolescent, are provided on-site or are available by referral; AND
               [Michigan Family Planning Standards and Guidelines, 2001: 9.3]



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            g. Male counseling services include a brief description of contraceptive
               methods, including sterilization; where to obtain contraceptive supplies;
               written and verbal instructions for use of spermicides and condoms;
               information regarding HIV/AIDS and STIs; and responsibility as a
               partner. [Michigan Family Planning Standards and Guidelines, 2001:
               8.1]


Q15.The local health department has protocols and
    operating procedures for providing clinical services.
    [State of Michigan MPR 9, 2001]
      Q15.1 Specific laboratory tests are required for the provision of specific methods
            of contraception.The local health department has specific protocols and
            operating procedures for laboratory services performed on-site. [Michigan
            Family Planning Standards and Guidelines, 19982001: 8.3 .5A1]

            To fully meet this indicator:

            a. Pregnancy tests must be provided on site; AND [Michigan Family
               Planning Standards and Guidelines, 19982001; 2001: 8.61A]

            b. The following laboratory procedures must be provided if required in the
               provision of a contraceptive method and may be provided for the
               maintenance of health status and/or diagnostic purposes, either on site
               of by referral; AND [Michigan Family Planning Standards and
               Guidelines, 19982001 8.3.5 A1b,

                       (1) Anemia assessment
                       (2) Gonorrhea and chlamydia test
                       (3) Vaginal wet mount
                       (4) Diabetes testing
                       (5) Cholesterol and lipids
                       (6) Hepatitis B testing
                       (7) Syphilis serology (VDRL, RPR)
                       (8) Rubella titer
                       (9) Urinalysis HIV testing

            c. A procedure which addressed client confidentiality must be established
               to allow for client notification and adequate follow-up of abnormal
               laboratory results AND [Michigan Family Planning Standards and
               Guidelines, 19982001; 2001:8.3.5A4c]

            d. The local health department maintains on file written policies and
               operating procedures for laboratory services performed on-site.
               [Michigan Family Planning Standards and Guidelines, 2001: 8.3 A]

            e. Lab services are performed in accordance with accepted medical
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               practice and CLIA regulations. [Michigan Family Planning Standards
               and Guidelines, 2001: 8.3.5, A3]

      Q15.2 The local health department provides revisit services in compliance with
            Title X requirements and Michigan Department of Community Health
            standards.

            To fully meet this indicator:

            Written protocols and operating procedures indicate that:

            a. Annual revisits are required for all clients using prescriptive methods;
               AND [Michigan Family Planning Standards and Guidelines, 2001: 8.3
               A1]

            b. Annual revisits include, at a minimum, a history update and a physical
               exam. Hormonal contraceptive users are asked about symptoms of
               embolic disease; pain in arms, chest, abdomen; headaches, visual
               problems; mood changes; leg complaints; irregular bleeding; and date
               and nature of the last menstrual period. Intrauterine device users are
               asked about abdominal complaints; irregular bleeding; fever; problems
               with device; vaginal discharge; and date and nature of the last
               menstrual period; AND [Michigan Family Planning Standards and
               Guidelines, 2001: 8.3.4]

            c. Medical revisits are individualized based on a client's need; AND
               [Michigan Family Planning Standards and Guidelines, 2001: 8.3 .4]

            d. The local health department maintains on file written protocols and
               operating procedures for revisit services. All procedures to be
               routinely repeated must be listed; AND [Michigan Family Planning
               Standards and Guidelines, 2001: 8.3 A]

            e. Annual revisits are recommended to all clients. The medical director ,
               per protocol, determines the frequency with which specific procedures
               are to be routinely repeated. [Michigan Family Planning Standards
               and Guidelines, 2001: 8.3.4 A1]

            f. Urinalysis is clients performed as medically indicated or per the
               request of a client. Serology, Hemagglutination test for Rubella, and
               pregnancy testing are administered if indicated or requested; AND
               [Michigan Family Planning Standards and Guidelines, 19982001:
               8.3.51b (1-7)]

            g. Return visits lab tests minimally performed for hormonal contraceptive
               users is an annual pap smear and for IUD users is an annual pap
               smear and hemoglobin or hematocrit; AND [Michigan Family Planning
               Standards and Guidelines, 19982001: 8.3 A1c (1-2)]


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            h. Medical, initial, annual and revisit clients receive the appropriate lab
               tests unless written results done within the last 12 months are
               available; AND [Michigan Family Planning Standards and Guidelines,
               19982001: 10.2B28.3 A1]

            i.   When medically indicated, assessment/screening for condylomata
                 acuminata (HPV), chlamydia, trichomonas, genital herpes, bacterial
                 vaginosis, candidiasis, syphilis, and gonorrhea is provided; AND
                 [Michigan Family Planning Standards and Guidelines, 19982001:
                 8.3.5A1b A6]

            j.   Microscopic examination is available at each clinic site; AND
                 [Michigan Family Planning Standards and Guidelines, 19982001: 8.3
                 C]

            k. Microscopic exam of vaginal or urethral smears and wet mounts for
               diagnosis of some sexually transmitted infections, vaginitis, and
               urethritis provided when indicated; AND [Michigan Family Planning
               Standards and Guidelines, 19982001: 8.35 C1]

            l.   Microscopic exam and/or culture and sensitivity of urine is provided;
                 AND [Michigan Family Planning Standards and Guidelines, 19982001:
                 8.3.5 C2]

            m. Selected blood tests including blood sugar, triglycerides/cholesterol,
               and HIV testing (if the local health department is a designated HIV
               Counseling and Testing Center) are conducted; AND [Michigan
               Family Planning Standards and Guidelines, 19982001: 8.3.5 C3]

            n. Quality control and equipment maintenance procedures, including
               proficiency testing, are in place for on-site lab testing. Quality Control
               logs are maintained; AND [Michigan Family Planning Standards and
               Guidelines, 19982001: 8.3.5 Aa3]

            o. There are lab log(s) and a system to identify, treat and follow-up
               abnormal results and selected conditions. Referral and follow-up
               procedures for abnormal test results include documentation of the
               appropriate management for abnormalities; client notification;
               confidentiality; referral of client for necessary services if not provided
               on site; AND [Michigan Family Planning Standards and Guidelines,
               19982001: 8.3 A45,

            p. Abnormal or unsatisfactory Pap Smear readings result in client
               notification within six weeks if further diagnostic study or repeat test is
               needed; follow-up contact noted in medical record; result of follow-up
               noted in medical record, the sending of a certified letter to unreachable
               clients if Pap Smear indicates dysplasia. AND


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            q. A registered certified letter is sent to the patient for results of a HGSlL
               or worse????? ; AND [Michigan Family Planning Standards and
               Guidelines, 19982001: 8.3.5 B]

            r. For positive gonorrhea, syphilis, chlamydia and HIV tests, state and
               local reporting requirements and follow-up procedures are followed.
               [Michigan Family Planning Standards and Guidelines, 19982001: 8.8
               A2]

      Q15.3 Local health departments using off-site laboratories are of high reliability
            and quality. [Michigan Family Planning Standards and Guidelines, 2001:
            8.3 A4]

            To fully meet this indicator:

            a. Labs reading Pap Smears must comply with their state licensing
               regulations; AND       [Michigan Family Planning Standards and
               Guidelines, 2001: 8.3.5 A34d]

            b. Has a system to assure lab tests performed by off-site laboratories are
               of high reliability and quality; AND     [Michigan Family Planning
               Standards and Guidelines, 2001: 8.3.5 A34]

            c. Competitively bids lab services contracts prior to award of contract.
               [Michigan Family Planning Standards and Guidelines, 2001: 8.3.5
               A34c]


Q16.The local health department has protocols and
    operating procedures for providing referrals and follow-
    up. [State of Michigan MPR’s 9 and 10, 2001]

      Q16.1 The local health department has policies for providing referrals for
            services not provided by the local health department. [Michigan Family
            Planning Standards and Guidelines, 2001: 7.4 A]




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            To fully meet this indicator:

            The local health department maintains on file:

            a. A referral list of providers, reviewed and updated periodically, that
               includes health care providers, local health and welfare departments,
               hospitals, voluntary agencies, and federally supported health services
               projects; AND [Michigan Family Planning Standards and Guidelines,
               2001: 7.4 A3]

            b. Policies and procedures, contracts, or operating agreements, that
               indicate formal arrangements for off-site required services are in place.
               If minimally required services are not offered at the local health
               department, referral arrangements must include a provision regarding
               reimbursement of cost; AND [Michigan Family Planning Standards
               and Guidelines, 2001: 7.4 A1]

            c. Procedures for referral must include fairness in selection of providers.
               [Michigan Family Planning Standards and Guidelines, 2001: 7.4 A3a]

      Q16.2 The local health department has specific protocols for follow-up or
            emergency, urgent, essential, and discretionary referrals. [Michigan
            Family Planning Standards and Guidelines, 2001: 7.4 A4]

            To fully meet this indicator:

            a. The local health department maintains on file policies for follow-up on
               emergency, urgent, essential, and discretionary referrals.

            b. When a client is referred for non-family planning or emergency
               clinical care the local health department must

            c. Make arrangements for the provision of pertinent client information to
               the referral provider. Agencies must obtain client consent to such
               arrangements, except as my be necessary to provide services as
               required by law with appropriate safeguards for confidentiality; AND

                   (1) Advise clients on their responsibility in complying with the
                       referral; AND

                   (2) Counsel clients on the importance of such referral and agreed
                       upon method of follow-up AND

                   (3) Efforts may be made to aid the client in identifying potential
                       resources for reimbursement of the referral provider, but health
                       departments are not responsible for the cost of the care, unless
                       the referral is a mandated minimum service AND
                   (4) Agencies must maintain a current list of health care providers,
                       local health a social services departments, hospitals and local
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                      health agencies and health services projects supported by other
                      Federal programs to be used for referral purposed. Whenever
                      possible, the clients should be given a choice of providers.
                      [Michigan Family Planning Standards and Guidelines
                      2001:7.4A3]

Q17.The     local   health    department     has     protocols
    whichprotocols that meet current standards of care for
    identifying, treating, and reporting sexually transmitted
    infections and HIV/AIDS. [State of Michigan MPR 20,
    19992001 Michigan Family Planning Standards and
    Guidelines 2001:9.2]
      Q17.1 The local health department has protocols whichprotocols that meet
            current standards of care for identifying, treating, and reporting sexually
            transmitted infections.

            To fully meet this indicator:

            a. The local health department maintains on file written protocols and
               operating procedures for identifying, treating, and reporting sexually
               transmitted infections; AND [Michigan Family Planning Standards and
               Guidelines, 19982001: 9.28.8 A]

                a. A review of medical records and STI written protocols and
                   operating procedures indicate that:

                b. Chlamydia and Gonorrhea testing is provided to all women
                   requesting an IUD, clients with exposure to and/or symptoms of
                   gonococcal infection, and high risk populations; AND [Michigan
                   Family Planning Standards and Guidelines, 19982001: 9.28.8 A1]

                c. VDRL/RPR test is provided as needed; AND [Michigan Family
                   Planning Standards and Guidelines, 19982001: 8.8 A5]

                d. Screening and treatment for STI's is provided as needed; AND
                   [Michigan Family Planning Standards and Guidelines, 19982001:
                   9.28.8 A6]

                e. State and local STI reporting requirements are met; AND
                   [Michigan Family Planning Standards and Guidelines, 19982001:
                   9.28.8 A2]

            b. Appropriate treatment and follow-up for STIs is conducted, including
               arrangements or referral for partner treatment; AND [Michigan Family
               Planning Standards and Guidelines, 19982001: 9.28.8 A3]


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      Q17.2 Local health department provides HIV/AIDS services related to individual
            client risk assessment, pre and posttest counseling and testing. [Michigan
            Family Planning Standards and Guidelines, 2001: 9.2B]

            To fully meet this indicator:

            a. Discussion with staff and review of credentials and training indicate
               that clinic staff are trained in HIV infection and AIDS and its prevention
               and transmission and infection control in a health care setting; AND
               [Michigan Family Planning Standards and Guidelines, 2001: 9.28.9
               AB1ed]

            b. Prevention counseling activities should assist clients in identifying risk
               of acquiring or transmitting disease by documenting acknowledged risk
               behaviors, negotiating and reinforcing plans to reduce or eliminate
               behavioral risk, and referring for medical and/or psychosocial services
               and follow-up; AND         [Michigan Family Planning Standards and
               Guidelines, 2001: 9.28.9 B]

            c. Policies and procedures for early medical intervention and referrals for
               all HIV infected clients to ensure psychosocial and medical care.
               Polices and procedures must reflect the local health department
               complies with the Quality Assurance Standards and Guidelines for HIV
               Counseling, Testing and Referrals, 1996; AND

            d. An intensive counseling and referral system is in place with on going
               monitoring for quality assurance indicators.

Q18.The local health department has protocols for providing
    contraceptive services that meet current standard of
    practice.   [Michigan Family Planning Standards and
    Guidelines, 2001: 8.4; State of Michigan MPR’s 1, 2, 3, 9,
    19, 20, and 21, 2001]

      Q18.1 The local health department has specific protocols for contraceptive
            management that meet current standard of practice.

            To fully meet this indicator:

            a. The local health department maintains on file written protocols for
               contraceptive management services provided either on site or by
               referral and protocols and procedures reflect current standards of care;
               AND [Michigan Family Planning Standards and Guidelines, 2001: 8.4
               A]

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            b. The local health department has established letters of agreement for
               services provided by referral; AND      [Michigan Family Planning
               Standards and Guidelines, 2001: 3.4 A18 and 19]

            c. The protocols must assure all Department of Health and Human
               Services approved contraceptive methods are provided on-site or by
               referral; that current medical guidelines related to relative and absolute
               contraindications for prescriptive methods are followed; and that
               education is provided regarding use of condoms/spermicides alone or
               in combination with other methods to decrease risk of HIV/AIDS and
               sexually transmitted infections; OR          [Michigan Family Planning
               Standards and Guidelines, 2001: 8.4 A1]

            d. The local health department requested and was granted a waiver for
               those services not available on-site. [Michigan Family Planning
               Standards and Guidelines, 2001: 7.10 C5b]

      Q18.2 The local health department provides contraceptive services in
            compliance with Title X requirements and Michigan Department of
            Community Health standards. [Michigan Family Planning Standards and
            Guidelines, 2001: 8.4 B]

            To fully meet this indicator:

            The local health department’s protocols include UP TO DATE and method
            specific instruction for use of:

            a. Diaphragms and cervical caps, including contraindications and
               procedures. Instruction must provide information on types available,
               how to choose the proper type, and fitting. Additionally, the procedure
               for at-home care of diaphragm, use instructions, and revisit schedule
               must also be included; AND [Michigan Family Planning Standards and
               Guidelines, 2001: 8.4 B1a]

            b. Condoms and spermicides, including dispensing and contraindications.
               Instruction must provide information on types available and use
               instructions; AND      [Michigan Family Planning Standards and
               Guidelines, 2001: 8.4 B1a]

            c. Intrauterine devices, including indications and contraindications.
               Instruction must provide information on types available, use
               instructions, and revisit schedule. Additionally, the procedures for
               insertion, removal, and missing IUD string must be included.
               Information on complications such as PID, perforation, pregnancy,
               expulsion, missing string; AND [Michigan Family Planning Standards
               and Guidelines, 2001: 8.4 B1b]



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            d. Norplant, or other implants, including contraindications, insertion and
               removal procedure, side effects, and revisit schedule. Possible
               complications such as inflammation at insertion site must be
               addressed; AND         [Michigan Family Planning Standards and
               Guidelines, 2001: 8.4 B1c]

            e. Oral contraceptives, including indications and determining the start
               date for the pill, provision to high-risk women, and contraindications.
               Information must be provided on use, supply visits, and revisit
               schedule. Additionally, the procedures for available pills and managing
               side effects must be included. Complications such as embolic disease
               must be addressed; AND [Michigan Family Planning Standards and
               Guidelines, 2001: 8.4 A1c]

            f. Injectible contraceptives, including indications and contraindications,
               visit frequency, and side effects. Complications such as decreased
               bone density and adverse lipid changes must be addressed; AND
               [Michigan Family Planning Standards and Guidelines, 2001: 8.4 A1c]

            g. Natural family planning, including instructions, contraindications, and
               revisit schedule; AND [Michigan Family Planning Standards and
               Guidelines, 2001: 8.4 A1d]

            h. Abstinence; AND        [Michigan Family Planning Standards and
               Guidelines, 2001: 8.4 A1e]

            i.   Sterilization, including contraindications. If services are provided on-
                 site, information on types of surgical procedures and male and female
                 sterilization must be provided. Additionally, complications such as
                 post-op bleeding, paralytic ileus, and allergic reaction to pre-operative
                 medications or to anesthesia must be addressed. A review of 10
                 randomly selected charts of clients receiving sterilization’s
                 demonstrates that the local health department is in compliance with
                 Federal regulations related to age, minimum to maximum time period
                 for consent, client is mentally competent, informed consent, regulations
                 for out-of-hospital surgery, referral process in place if sterilization not
                 offered on-site, and follow-up/revisits; AND [Michigan Family Planning
                 Standards and Guidelines, 2001: 8.4 B2]

            j.   Emergency Contraception, including compliance with Federal Drug
                 Administration guidelines for use of postcoital medication; DES is not
                 used; birth control counseling is conducted; and a pregnancy test is
                 performed if indicated prior to treatment; AND [Michigan Family
                 Planning Standards and Guidelines, 2001: 8.4, B1c]

            k. Each of the local health department’s clinics maintains on-site an
               adequate supply and variety of drugs and devices to meet the
               contraceptive needs of clients.    A review of the supply of


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                 contraceptives in stock includes: [Michigan Family Planning Standards
                 and Guidelines, 2001: 10.2 A5]

                    1. Oral contraceptives in a variety of dosages and combinations;
                       AND
                    2. IUDs, Norplant systems, and injectible contraceptives if
                       provided on site; AND
                    3. Diaphragms/cervical caps in various types and sizes; AND
                    4. Male and female condoms; AND
                    5. Spermicidal agents such as foams, creams, jellies, film; AND
                    6. Emergency contraceptive pills AND

            l.   Method counseling is conducted and includes the following: [Michigan
                 Family Planning standards and Guidelines 2001:8.3B3]

                    1. Results of physical exam and lab studies AND
                    2. Effective use of contraceptive methods, including natural family
                       planning (NFP), and the benefits and efficacy of the methods
                       AND
                    3. Location where emergency services can be obtained AND
                    4. Appropriate referral for additional services as needed.


Q19.The local health department has protocols and
    operating procedures for pregnancy diagnosis and
    counseling services. [State of Michigan MPR’s 9, 10,
    and 20, 2001]

      Q19.1 The local health department provides pregnancy diagnosis and counseling
            services in compliance with Title X requirements and Michigan
            Department of Community Health standards. [Michigan Family Planning
            Standards and Guidelines, 2001: 8.6 A]

            To fully meet this indicator:

            a. The local health department’s protocols and operating procedures for
               pregnancy diagnosis and counseling assure that:

                    1) Pregnancy diagnosis and counseling is provided to all clients in
                       need of this service or at clients request (7-10 days after
                       possible conception); AND        [Michigan Family Planning
                       Standards and Guidelines, 2001: 8.6 A1, 8.3 A2]

                    2) A client chart is maintained; AND



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                  3) Pregnancy diagnosis services consist of a signed consent form,
                     comprehensive history, physical exam, including pelvic exam,
                     when indicated, pregnancy test, and repeat testing of those with
                     negative tests whose history and physical exam are indicative of
                     pregnancy; AND [Michigan Family Planning Standards and
                     Guidelines, 2001: 8.6 A2]

                  4) Pregnancy counseling consists of information provided in a non-
                     directive, unbiased manner; AND [Michigan Family Planning
                     Standards and Guidelines, 1998: 8.6 A3]

                  5) Information on all options is provided, if requested by the client;
                     AND [Michigan Family Planning Standards and Guidelines
                     2001: 8.6A3.a]

                  6) For a positive test, information and counseling must be offered
                     and appropriate referral information are provided on pregnancy,
                     prenatal care and delivery, infant care and adoption, pregnancy
                     termination, family planning, especially with women having
                     unplanned pregnancies, and good health practices during early
                     pregnancy; AND [Michigan Family Planning Standards and
                     Guidelines, 2001: 8.6 3A1]

                  7) For a negative test counseling is provided on retesting and
                     revisit appointments, as indicated and available contraceptive
                     and infertility services; AND     [Michigan Family Planning
                     Standards and Guidelines, 2001: 8.6 3A2]

                  8) If a medical exam is not done at the time of testing, the client is
                     counseled as to the importance of receiving a physical exam as
                     soon as possible, preferably within 15 days; AND [Michigan
                     Family Planning Standards and Guidelines, 2001: 8.6 3A3]

                  9) Suspected ectopic pregnancies are referred for immediate
                     diagnosis and treatment and follow-up process is in place.
                     [Michigan Family Planning Standards and Guidelines, 2001: 8.6
                     B]; AND

                  10)STI/HIV education is given and testing offered and documented
                     in the chart; AND [Michigan Family Planning Standards and
                     Guidelines, 2001: 8.8 B1, B2, 8.1 A8] 8.0A11, 9.2.1, 8.1A12]

                  11)Condoms are offered; AND          [Michigan Family Planning
                     Standards and Guidelines, 2001: 8.1 C3]

            b. Discussions with clinic staff and by observation of patient-client
               interaction and review of credentials and training indicate that clinic
               staff have knowledge of the above standards.


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Q20.The local health department has protocols and
    operating procedures for infertility services. [State of
    Michigan MPR’s 9, 10, and 20, 2001]

      Q20.1 The local health department has specific protocols for providing infertility
            services.

            To fully meet this indicator:

            a. The local health department maintains on file written protocols that
               identify the services to be provided, criteria for diagnosis of infertility,
               identification of referral sites, follow-up, fee schedules and payment
               mechanisms; AND           [Michigan Family Planning Standards and
               Guidelines, 2001: 8.5 A2]

            b. The local health department’s protocols for infertility services assure
               that at a minimum Level I services are offered, including: [Michigan
               Family Planning Standards and Guidelines, 2001: 8.5 A1]

                   1) Initial interview or assessment
                   2) Education/Counseling
                   3) Physical Examination
                   4) Lab testing including Hgb/Hct, Pap smear, Gonorrhea testing,
                      and other STI's, especially Chlamydia
                   5) Optional testing within the scope of the local health
                      department’s program, i.e., basal body temperature charting
                   6) Referral services; AND

            c. Clients are encouraged to have her/his partner participate in decisions
               related to infertility services; AND     [Michigan Family Planning
               Standards and Guidelines, 2001: 8.5 D]

            d. If applicable, for any Level II services offered (semen analysis,
               assessment of ovulatory function and post-coital testing) protocols are
               in place that meet minimum requirements; AND [Michigan Family
               Planning Standards and Guidelines, 19982001: 8.5 B]

            e. If applicable, for any Level III services offered protocols are in place
               that meet minimum requirements.            [Michigan Family Planning
               Standards and Guidelines, 1998: 8.5 C]




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Q21.The local health department has protocols and
    operating procedures for identifying and assuring
    treatment of estrogen-exposed offspring.

I     Q21.1 The local health department identifies and assures treatment of estrogen-
            exposed offspring born between 1940 and 1970. [Michigan Family
            Planning Standards and Guidelines, 2001: 8.8 A]

            To fully meet this indicator:

            a. The local health department maintains on file written protocols and
               operating procedures to identify estrogen-exposed offspring. The
               protocols and procedures must use the following methods to identify
               and treat estrogen-exposed offspring:

                   1) Clients with prenatal exposure to estrogen receive special
                      screening either on-site or by referral.    [Michigan Family
                      Planning Standards and Guidelines, 2001: 8.8A]

                   2) Females with prenatal exposure are given appropriate
                      counseling, and a referral for colposcopy is made. [Michigan
                      Family Planning Standards and Guidelines, 19982001: 8.10
                      B38.8B2]

                   3) Males with prenatal exposure are given appropriate counseling.
                      [Michigan Family Planning Standards and Guidelines, 2001:
                      8.10 B48.8B3]




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THIS SECTION TO BE COMPLETED ONLY IF SERVICES ARE OFFERED ON-SITE


Q22.The local health department has protocols and
    operating   procedures for screening for minor
    gynecologic problems.

I     Q22.1 The local health department has up to date protocols for screening for
            breast conditions and minor gynecologic problems. [Michigan Family
            Planning Standards and Guidelines, 2001: 9.2]

            To fully meet this indicator:

            The local health department:

            a. Maintains on file written protocols and operating procedures for
               screening for breast conditions and minor gynecologic problems; AND

            b. Diagnosis and treatment of minor gynecologic problems are provided
               on-site (e.g. vaginitis, dysmenorrhea, secondary amenorrhea).


Q23.The local health department has operating procedures
    for genetic screening with referral if indicated.

I     Q23.1 The local health department provides screening and referral
            procedureshas protocols and operating procedures for genetic
            conditionsscreening and referrals. [Michigan Family Planning Standards
            and Guidelines, 19982001: 9.43]

            To fully meet this indicator:

            The local health department:

            a. Offers initial genetic screening and referral services that are supported
               by a program of public information and education sensitive to concerns
               of local ethnic and religious groups and upholds the dignity of
               individuals with congenital physical or mental limitations; AND
               [Michigan Family Planning Standards and Guidelines, 1998: 9.3 A, 9.3
               A4a]

            b. Refers to a genetic counselor if more complete genetic screening and
               counseling offered and has linkage with a genetic service program and
               other referral providers; AND [Michigan Family Planning Standards
               and Guidelines, 1998: 9.3 A1a]

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            c. Documentation that staff have been trained to provide basic in simple
               genetic informationscreening; AND       [Michigan Family Planning
               Standards and Guidelines, 19982001: 9.43 A2]

            d. Literature and informational materials, including information on
               Michigan Department of Community Health’s state-wide genetic
               screening program, are available for all clients if requested. [Michigan
               Family Planning Standards and Guidelines, 2001: 9.3 4A3]


Q24.The local health department has protocols and
    operating procedures for providing special gynecologic
    procedures.

I     Q24.1 The local health department has protocols and operating procedures for
            providing special gynecologic procedures. [Michigan Family Planning
            Standards and Guidelines, 2001: 10.0]

            To fully meet this indicator:

            The local health department:

            a. Maintains on file up to date written protocols and operating procedures
               for providing special gynecologic procedures, such as colposcopy,
               biopsy, and cryosurgery; AND [Michigan Family Planning Standards
               and Guidelines, 2001: 10.0 A]

            b. Maintains on file evidence, such as letters or memoranda, that such
               services provided on-site have been approved by the Michigan
               Department of Community Health; AND [Michigan Family Planning
               Standards and Guidelines, 2001: 10.0 B]

            c. If colposcopy or related services are provided the supervising
               physician must have training and according to MDCH standards and
               maintains current affiliation with a JCAHO accredited back-up hospital;
               AND     [Michigan Department of Community Health Colposcopy
               Guidelines (1997)]

            d. Midlevel clinicians have completed a preceptorship under the direct
               supervision of an approved preceptor and a course outline,
               preceptorship requirements and faculty are available for review; AND

            e. A physician colposcopist is available by phone whenever patients are
               seen, evaluates problem cases referred by midlevel practitioners,
               reviews each chart and countersigns prior to treatment and at least
               annually, and evaluates and documents the skills of the midlevel
               practitioner; AND
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            f. All practitioners maintain evidence of continuing education course
               within   the     last 10    years    with   cervical disease  and
               colposcopy/cryotherapy as its main focus; AND

            g. Up to date policies and procedures are in place describing the agency
               philosophy related to colposcopy/cryotherapy, staffing and staff
               responsibility, patient selection criteria, absolute contraindications to
               patient eligibility, fact sheets and educational materials, informed
               consent, counseling, documentation and use of the medical record,
               refusal of colposcopy after counseling, documentation in the medical
               record, informed refusal signed by the client, set up and clean up of
               examination room and aseptic technique; AND

            h. Colposcopic exam procedures include              endocervical curettage,
               colposcopic punch biopsy, hemostatic             agents/instruments and
               handling of biopsy specimens; AND

            i.   Cryotherapy procedures include prior review of pathology report,
                 management of intra-procedure complications, management of post
                 procedure complications and referral management and follow-up; AND

            j.   Medical records are maintained in accordance with accepted medical
                 standards and a system exists for retrieving records of patients by the
                 date of service, clinician or complications; AND

            k. Correlation data for pap smear, colposcopic diagnosis and histologic
               diagnosis are gathered and maintained; AND

            l.   Complication logs and summaries are maintained; AND

            m. The physician director and quality assurance committee routinely
               monitors individual rates. Patient care audits are conducted at least
               annually; AND

            n. Policies and procedures exist for the management of complications,
               emergencies and adverse outcomes which include the management of
               after hours problems and complications, the management of out of
               town patients and the documentation of emergencies and adverse
               outcomes; AND

            o. Clients are counseled about Hepatitis B and vaccination is offered on-
               site for clients at risk.




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                                     APPENDIX E

           General Clinic Procedures and Clinician Service Protocol

                           SECTION 7.0 CLIENT SERVICES
                              EVALUATION CRITERIA



7.1   Service Plans and Protocols                              YES    NO     COMMENTS

      Review General Clinic Procedures and Clinician
      Service Protocols for compliance to Title X and
      MDCH requirements look at personnel file of
      medical director and/or clinician’s for documentation
      of annual review of manual and follow at least one
      client through clinic to assess compliance of staff to
      regulations.

A.    General Clinic Procedures and Clinician Service
      Protocol and Clinician Service Protocol Manual(s)
      are in place and reviewed annually.                      ___    ___

      1.     General clinic procedures and clinician
              protocols are in compliance with Title X and
              accepted medical practice.                       ___    ___
      2.     General clinic procedures and clinician
              protocols are reviewed annually, updated as
              indicated and signed by medical director and
              clinicians.                                      ___    ___
      3.     Any change/addition in protocol occurring
              between annual reviews is signed and dated
              by affected staff members at time change
              occurs.                                          ___    ___
      4.     Clinical staff members function according to
              established protocols outlining qualifications
              and responsibilities.                            ___    ___




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                                                            YES    NO     COMMENTS

B.    General Clinic Procedure and Clinician Protocol

      Manual(s) includes details on:

      1.    Specific procedures performed for:
            a.       Initial visit                          ___    ___
            b.       Annual visit                           ___    ___
            c.       Revisits, including supply visit,
                     pregnancy testing and counseling.      ___    ___
            d.       Clinical procedures and clinical
                     protocols reviewed annually            ___    ___
      2.    The frequency with which procedures are to
            be routinely repeated.                          ___    ___
      3.    History and physical exam requirements for
            each visit type.                                ___    ___
      4.    Permanent, temporary and emergency
            contraception.                                  ___    ___
      5.    Informed consent.                               ___    ___
      6.    Client eligibility                              ___    ___
      7.    Supply distribution.                            ___    ___
      8.    Client education and counseling                 ___    ___
      9.    Service to minor’s.                             ___    ___
      10.   Pregnancy diagnosis and counseling              ___    ___
      11.   Medical follow-up.                              ___    ___
      12.   Laboratory testing.                             ___    ___
      13.   Referral procedures.                            ___    ___
      14.   Infertility services.                           ___    ___
      15.   Emergencies                                     ___    ___
      16.   HIV/AIDS education and counseling.              ___    ___
      17.   Equipment and supplies.                         ___    ___
      18.   Medical records.                                ___    ___
      19.   Confidentiality and release of records.         ___    ___
      20.   Quality assurance                               ___    ___
      21.   Standing orders.                                ___    ___
      22.   Job description; responsibilities of Clinic
            personnel.                                      ___    ___
      23.   Medical supervision.                            ___    ___
      24.   Pharmaceuticals                                 ___    ___
      25.   Any other services provided                     ___    ___
      26.   Clinic flow for client visit.                   ___    ___
      27.   Management of reproductive diseases/
            disorders.                                      ___    ___




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                                                            YES    NO     COMMENTS

      28.   Sexually transmitted infections                 ___    ___
      29.   Management of high risk contraceptive
            clients.                                        ___    ___

C.    Waiver request has been submitted for
      exemption from a particular requirement.              ___    ___

      1.    If yes, what requirement
      2.    Waiver was approved by MDCH                     ___    ___




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